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Technical Assistance Call for Applications to AHRQ's Transforming Primary Care Practice Funding Opportunity Announcement (FOA)

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Moderator: David Lanier:
September 25, 2009
12:00 p.m. CT

This document summarizes the technical assistance call for AHRQ-sponsored funding opportunity announcements (FOAs) on transforming primary care. Select to access the FOAs.

The technical assistance teleconference was held at the Agency for Healthcare Research and Quality (AHRQ) conference center in Rockville, MD, on September 25, 2009. If after reading this document you have any questions or comments, contact

Coordinator:: Welcome and thank you for standing by. At this time, all participants are in listen-only mode until the question and answer session of today's conference. At that time, you may press star one on your touch-tone phone to ask a question.

I would also like to reminder parties that this call is being recorded. If you have any objections, you may disconnect at this time. I would now like to turn the call over to Dr. David Lanier:. Thank you. You may begin.

David Lanier: Thank you and welcome everyone. I want to make sure everyone understands this is our technical assistance call to discuss HS-10-002, Transforming Primary Care Practice. I'm joined today by Cindy Brach, who will cohost this with me in answering your questions. She's from the Center for Delivery, Organization, and Markets at AHRQ.

We're also joined by three people from our Office of Research Review, whom I won't introduce individually. I'm letting you know they are all three here to keep us honest and to help answer any questions that we're not able to answer ourselves. The purpose of this call is to get at questions that you have or clarifications that would be useful to you in potentially responding to this RFA. Before we actually go to your specific questions, I want to make a few points.

This RFA was released about 6 weeks ago, and during that time Cindy and I have received a number of e-mails and questions by phone from you. We have been looking these over and have found some common themes and have come up with a group of questions that we have put the answers to in writing.

All of you, if you registered for this call, should have received a copy of those specific questions with answers to them. We do not intend to spend time going over those, so before you ask your question, I would ask you, if you haven't already, to refer to that list and just be sure your question has not already been answered in the information we've sent out.

I also want to remind folks that we know that there are a number of questions that may be very specific for your institution or your situation, and we really don't think it's wise to spend everyone's time discussing a particular specific issue that would apply only to you or your institution. Instead, if you have those questions, we would encourage you to either e-mail or call one of us and we'll be happy to provide an answer for you.

Also, before we begin, I want to provide a little bit of background information about AHRQ's interest and how this RFA evolved, because I think that sort of background information will be helpful to you in understanding the answers that we've provided to some of your questions.

Let me begin by saying that if you're at all familiar with AHRQ, you understand that this agency has been on the forefront in terms of trying to improve the delivery of health care in the United States, with the overall goal of improving the health and health care that's received by Americans.

An important part of that has been improving the care provided in primary care settings, where most Americans receive the majority of their care. Most of the efforts to improve care up to this point have been what I will call incremental improvements in care. That is, people have recognized a challenge or problem in practice and have come up with an approach or specific intervention that would address that, such as disease registries or reminder systems. This has resulted in what I would call evolutionary improvement in care within primary care settings. However, in the past 5 years or so, the climate seems to have changed quite a bit in primary care.

The leaders in primary care have described what they call a crisis in primary care. The thought is that the infrastructure currently being used in primary care is insufficient to do the work that needs to be done. There's greater stress and pressure on providers of care with increasing demands and lower reimbursement, and there's an increasing trend of students choosing not to go into primary care specialties.

With a crisis situation like this, the result has been that we need more than incremental change in primary care in order to be able to provide the services that Americans need. The thinking on this issue has revolved around a concept that's known as a patient-centered medical home. While there are a lot of definitions of what the patient-centered medical home is, we provide in the RFA some references that you can look at, if you're not specifically familiar with that concept.

We have not provided a specific definition, but I can say in general as we describe in the RFA, that we're talking about a model for organizing primary care that establishes an ongoing partnership between patients and practices so that services are comprehensive and accessible and affordable.

You'll find in the RFA a list of potential components of the patient-centered medical home, which include team-based care, orientation toward the whole person, continuous and accessible services, care coordination, connectivity to the rest of the health care system as well as community resources, and a type of care that systematically addresses quality and safety.

You'll notice that I didn't specifically mention health IT. AHRQ recognizes that this can be an extremely important part of a patient-centered medical home, but we don't think it's the sine qua non. In fact, when the pediatric community began doing this earlier, they started their transformation and came up with the term patient-centered medical home in the late 1960s and early 1970s before electronic health records were in existence.

So we think it's a useful thing, but simply having health IT does not necessarily mean that there's a total transformation and redesign of the practice.

What I want to stress is that we are looking for not incremental changes that have occurred over years and years in practices, but a type of revolutionary change that people have taken. And they began their transformation at least a year before the time that your application is submitted to the system here.

We are aware that there have been a number of formal demonstration projects around the country, such as TransforMED that was supported by the American Academy of Family Physicians, that have had some evaluation components attached to them, some of them quite sophisticated evaluations through the Commonwealth Fund. But there also have been other experiments and unofficial or self-funded attempts to transform primary care practices. As long as those had been ongoing for at least a year, we're interested in those as well.

What we specifically want you to do is to identify groups of practices that have undergone this revolutionary type of change that we're talking about: a total redesign of practice and systemic changes throughout. Take a hard look at those practices that have been successful by some criteria that you can define. We are particularly interested in your showing us how process measures, and also to the extent possible patient outcome measures, have improved as a result of those transformation processes that have taken place.

Beyond that, we really want you to tell us how this happened. What were the lessons learned, what were the ways in which challenges were overcome? We would like to be able to report to other practices who subsequently undertake similar types of changes what the lessons learned are so that we can help them get from Point A to Point B easily and more successfully.

We also are interested in the cost of that care, both to the practice and to the health care system, because that makes a business case for other groups doing this.

Let me also make clear what we're not interested in. We're not interested in new efforts to transform practices that you are going to begin some time in the near future. This RFA is to look at practices that have already done that for at least a year and have shown some success in that process.

We're not interested in ongoing efforts, no matter how long they've been going on, that have been incremental. It also would be problematic if you have efforts that have been incremental over many years and have after, say, 4 or 5 years, resulted in something that looks like a patient-centered medical home. The reason for that is it's very difficult for us to be able to evaluate, because of secular trends that could have occurred over that long period of time, exactly how it happened and what we could ascribe any improvements to. It also is a different process than this sort of total redesign that would occur simultaneously.

We also are not interested in looking at a single intervention or a couple of interventions. We're looking at efforts to totally redesign the practice of primary care.

So let me stop here and see if there are other things Cindy wants to add.

Cindy Brach: I just want to maybe underscore a couple of things. One phrase that might help stress that we're looking to study transformations that have happened is that we're seeking to take advantage of “natural experiments.” We feel that there has been a lot of experimentation in the field that, that there are people who have already learned a lot about transformation. What we are trying to do is exploit that and learn from those experiences.

We've had some questions about how many practices have to be studied. Our answer is that you should ask yourself whether the group of practices that you propose to analyze would generate lessons that would be of national interest. That is, can you produce information about how to transform that primary care practice from a non-patient-centered medical home to a patient-centered medical home?

David Lanier: I think that provides enough of a background and context. We're going to have about 45 minutes for questions. We hope we'll be able to get to all the questions that you have. What I will ask is for our coordinator Diane to give instructions one more time about how you get in the queue and how you would actually get the microphone. Diane?

Coordinator: Thank you. We will now begin the question and answer session. If you would like to ask a question, please press star one. Please unmute your phone and record your name clearly, and also your organization when prompted. Your name is required to introduce your question. To withdraw your request, press star two. One moment, please, while we wait for the first question.

Coordinator: Marie DiCowden, and please state your organization.

Marie DiCowden: Hi, yes. I'm with Biscayne Foundation and Biscayne Institute. I was wondering if it's possible, based on information we have so far, to submit a concept paper of say five to seven pages within the next week in order to receive some initial feedback. If so, who should this concept paper be sent to?

David Lanier: We are getting a huge number of requests here, and I think a concept paper as long as five pages would be difficult, especially if we had hundreds of these coming in, to respond to. We simply don't have the resources to be able to provide detailed technical assistance. If you could put your concept into a few sentences or a paragraph, if you could compress it that much...

Marie DiCowden: Yes.

David Lanier: ...I think we would certainly have time to be able to tell you if you're in the right ballpark.

Marie DiCowden: O.k.

David Lanier: So I hope that will be acceptable to you.

Marie DiCowden: Yes. And who would that be directed to?

David Lanier: That would be me.

Marie DiCowden: O.k., that's what I thought. Thank you very much.

David Lanier: Yes. Let me add to that. It would be me or Cindy and it would be through the PCTransform e-mail address that's listed in the RFA [].

Marie DiCowden: O.k. Thank you.

Coordinator: Our next question comes from Shelly Sherry from the Minnesota Department of Health. Your line is now open.

Shelly Sherry: Hi. I'm wondering if you can tell me specific outcomes that would demonstrate to you that a practice has been transformed?

David Lanier: We could give you some examples, but we are not requiring that you use specific outcomes. The outcomes that you're interested in may vary with the type of transformation that has gone on in your practices.

There are two major categories that are listed in the RFA. One of them is specific process measures. For instance, it could be fairly disease specific if you want it to be, the extent to which hemoglobin A1c levels have been drawn periodically for diabetics, the extent to which foot exams or eye exams have given to diabetics. It could be other process measures, such as the percentage of people eligible who receive appropriate vaccinations or screening procedures for preventive services.

We're also quite interested, but again it would depend on the amount of time the transformations have been in place, in specific patient health outcomes. For instance, outcomes related to the care of diabetes or of asthma, such as whether hemoglobin A1c levels are trending toward better control, children with asthma are being seen in emergency rooms less frequently, or certain patients are being admitted to hospitals less frequently.

As you can tell, it takes a longer time to accrue those types of benefits from changes in the system, and it may or may not be appropriate.

Cindy Brach: I'll add another class of potential outcomes that you can look at, which are access measures. For example, the wait time for an appointment. Another type of outcome that could be measured is patients' experiences of care.

David Lanier: Does that answer your question?

Shelly Sherry: Yes, thank you.

David Lanier: O.k.

Coordinator: Our next question comes from Mark Freeberg, Rand Corporation. Your line is now open.

Mark Freeberg: Hi, thank you. My question is just a clarification on the time that the transformation has been going on. Is it a year as of the time that the grant application is due, or would it be a year as of the time that the evaluation, should it be funded, would start?

David Lanier: Our strong preference would be that it has been a year by the time you submit your application.

Cindy Brach: One of the things that we ask for in the application is some evidence that it has been successful. Obviously, you're being funded to do the evaluation. You would only have some preliminary data, but our goal is to learn from places that have been successful in transforming their practices. Therefore, you need to have been able to achieve something and produce some evidence of that for the application.

Mark Freeberg: Thank you.

Coordinator: Chessis Torres, and please state your organization.

Chessis Torres: Genesis Health System in Flint, Michigan. You spoke about the idea of needing this not to be incremental changes but to be, you know, a dramatic transformation from not a patient-centered medical home to yes we are a patient-centered medical home.

And that sounds pretty black and white, but my experience is that it's a lot more gray—that there are some kind of developmental efforts that have happened over years and years, and then there's also some more dramatic transformational type of work that has occurred over a short period of time. Is that going to be something that you would not be interested in?

David Lanier: I hate to hedge here, but I would not tell you that it is something we would not be interested in. It will be up to the study section who reviews the applications to determine if these changes that you describe—and I would really encourage you to describe them in enough detail that we have a clear understanding of what's happened and when it's happened—are transformational or not. They would make that decision.

I totally understand what you're saying, because practices that are in the forefront of trying to improve their care don't suddenly shift from never having any changes to total changes, or that rarely happens. We would expect that some incremental improvements have been going on in practice, even those who choose at some point to then undergo a more total transformation.

So my advice to you would be to describe very carefully what has happened. And I would certainly say that you're not going to be eliminated or not considered because of work that has been done prior to what would be the sort of transformative moment.

Chessis Torres: Thank you.

Coordinator: Diane Rittenhouse, UCSF, your line is now open.

Diane Rittenhouse: Hi, I just had a question about the review process. I'm just curious whether or not this was going to be reviewed by a standing committee or an SEP [Special Emphasis Panel].

David Lanier: Yes, I can give you the answer to that. There are more detailed answers. We have other people here who can talk about it, but it will be going to a Special Emphasis Panel that will be put together that has the appropriate expertise to address these issues in primary care. And it will take a broad spectrum of expertise to look at all the types of transformation and also the evaluation that will be involved in this RFA.

Diane Rittenhouse: Thank you.

Coordinator: We have a question from Charles McLean, University of Vermont. Your line is now open.

Charles McLean: Thank you. I had a question about whether or not there was any special interest in the integration of mental health and behavioral health providers into the patient-centered medical home.

David Lanier: There absolutely is a lot of interest in that, but let me just emphasize that that needs to be part of a larger package. Just as I said, an important part of this would be connectivity to other resources in the community and other parts of the health care system. So integrating mental health providers into primary care could be an important component of that.

But we would not interested in something that was exclusively that. If it had a transformation that was just limited to integrating mental health services, that would not meet the spirit of the RFA, but would be strongly encouraged as a component of that.

Cindy Brach: And to just broaden that idea a little bit in the spirit of what we're not looking for. We are not looking for an evaluation of a quality improvement project. That is, you may have done some fabulous quality improvement project, but if it is a sort of single effort, or discrete project, that isn't transforming how you deliver care overall, then it doesn't fit this RFA.

But let me also take this opportunity to say that AHRQ is a funding agency, and if you don't fit this RFA you should still stay tuned to our funding opportunities page on the Web. We are going to be coming out with more solicitations.

Charles Mclean: Thank you.

Coordinator: Our next question comes from Marsha Neff, Trinity Health. Your line is now open.

Marsha Neff: Thank you. I have also been multitasking and reading the questions that you e-mailed yesterday and I may have my answer, and that is whether you would be open to a study that involved some additional transformation.

We certainly wouldn't be speaking of clinics that we believe are pretty far along in patient-centered medical homes, so it's not like we're going to use this study to do that. But if you would be open to some additional transformation...

Cindy Brach: Marsha, let me see if I'm understanding your question correctly. One of the things that we tried to recognize in our questions and answers document is that we realize that practices are dynamic places. It's not like you've transformed—ta da—and you're going to be static from then on. There is going to be continual transformation going on.

So, yes, it's fine to keep transforming during the study period. You will, of course, need to address that difficult situation in your evaluation methodology—of how you're going to take into account the fact that 6 months after you began the study things aren't being done exactly the same way they were at the beginning. I think you've understood that the purpose of the research is not to study something that is new. But we certainly don't want to squelch folks because they realize that they're going to continue changing.

Marsha Neff: All right. So we described what has already happened, the process and the outcomes, to show you that we have produced evidence of improving quality of care. But if we are proposing to do some additional changes during the grant period, we can also integrate that, as long as we carefully explain it and realize that new evidence about that will be new evidence, et cetera.

Cindy Brach: Yes, you can do that. But I would say we're not encouraging you to.

Marsha Neff:Oh, o.k.


David Lanier: And you'd still have to stay within the confines of the budget that's allowed. If that is sapping funds from doing the main part of the work, that could be a problem with an application. That would be the only warning that I'd give you.

Marsha Neff: O.k., thank you.

Coordinator: Our next question comes from Lisa Letourneau, Quality Counts. Your line is now open.

Lisa Letourneau: Hi, thank you very much. My question relates to the type of support that has assisted practices with the transformation. Specifically, is it important to the application process that it be a consistent intervention, or is it o.k., for example, if you had 12 or 15 practices if they underwent different types of support in their own communities or systems to get to their current state of medical wholeness? Does the consistency of the intervention matter as long as you could describe what happened and what the contributions were?

David Lanier: The second part of your sentence is the important thing—that you can describe what it is. The extent to which there is at least some elements that are common to all of the practices, that would be far preferable than if you had totally disparate elements. That would be like 12 studies with an N of one, which would be a little bit more difficult for us to draw any broad conclusions from, than if there were at least some common elements that they shared.

So you will not have struck out with that, but you need to be very careful how you describe it, and explain to us how that's going to give us some useful information.

Lisa Letourneau: Great. Thank you.

Coordinator: We have a question from Natalie Levkovich, Health Federation of Pennsylvania. Your line is now open.

Natalie Levkovich: Thank you. My question is, if we are working with federally qualified health centers who have undertaken transformation at some point in the past—obviously more than a year ago—and we're measuring improvements, where does the baseline come from?

David Lanier: Well,that could be a problem if it's difficult for you to draw a line in the sand and say, “Before this.” It gets into what I was discussing before, this very slow accretion of improvement over such a long period of time that it's difficult to know where the baseline is.

So I would look back, and if there were one time in which you made a major push for this by instituting some major changes, call that the start of your transformation. But you need to describe it very carefully in the application.

Natalie Levkovich: And so there'd been an expectation of going back and getting retrospective data by some means.

David Lanier: Yes. And that's one of the requirements in the RFA, that you have to demonstrate that you have the availability of data to provide a baseline against which we can determine that improvements have been made in the delivery or quality of care.

Natalie Levkovich: Thank you.

David Lanier: Yes.

Coordinator: Our next question comes from Catherine Schneider, Atlanta Care. Your line is now open.

Catherine Schneider: Yes, thank you. I think my question relates to what is really the unit of study that you're defining as the practice. I noticed in your written questions, you very specifically excluded a practice that had been started up from scratch as a patient-centered medical home. But if that was part of a health system that is implementing PCMH as a broader strategy, would that qualify in terms of looking at communitywide outcomes or payerwide outcomes? Thanks.

Cindy Brach: It doesn't matter what the clinic is attached to. The issue is that we are interested in the transformation: going from one state to another. So if you're opening a new clinic and you've used a blueprint of patient-centered care to design this clinic to be patient centered, it's not going to give us the information we're looking for. It's not that this does not merit evaluation, but we want to tell practices that are out there now how they can change.

That's why that [a brand new clinic] would be excluded, irrespective of what larger system they were part of.

Catherine Schneider: Thank you.

Coordinator: Our next question comes from Susan Payne, Mesquite School of Service. Your line is now open.

Susan Payne: Yes, thank you. I have a...can you hear me?

Cindy Brach: Yes.

Susan Payne: O.k., good. I have a question that relates partly to the definition of patient-centered medical home and partly to the timing question. What we're looking at is evaluating a group of several practices in a statewide demonstration project, and they would reach a basic level of being patient-centered medical homes and also receive reimbursement for functioning as patient-centered medical homes. So that would be the transformation that they're undergoing.

They would achieve that by October of this year. If the funding began several months from now, they would have achieved that transformation and be continuing to move toward higher levels of functioning as patient-centered medical homes by the time research started. So I'm wondering if that would be something that you would consider in terms of this request for proposals.

David Lanier: Well, first of all, I think that it's interesting that you're doing that. But, to repeat, we want transformations that have been in place for a year, preferably by the time you apply. So if the transformations are only going to be realized around October, that's not enough time for us to know that the transformations are successful. So that would be the problem with an application like that.

Susan Payne: O.k., I understand. So part of the reason I had a question was because some of the language refers to the time the application was submitted, and some refers to the time the research starts. So this is helping me become clear, because you're saying even at the time the research starts, it won't have been a year.

David Lanier: And the reason for that is you have to demonstrate in your application that you have at least some evidence of success. And if it's been less than a month that it's been actually in place, there's no way that you can demonstrate that in your application.

Susan Payne: O.k., thank you.

Coordinator: Our next question comes from Shelly Sherry, Minnesota Department of Health.

Shelly Sherry: Hi. I'm wondering if you can tell me, with all the different instruments there are right now that measure patient-centered (unintelligible) patient experience and also clinical practice or redesign, will you be giving preference to any sort of framework or instruments that would be used to measure these kind of components? Do you have preferences for what we should be using?

David Lanier: As I said, we haven't even agreed on what a definition of the patient-centered medical home would definitely be, and so we definitely do not want to endorse one [framework or measures of patient experiences of care] over the other. My advice would be to take a look at these and see which one best suits your purposes and use that in your application.

Shelly Sherry: Thank you.

Coordinator:: And again if you do have any questions or comments, please press star one and record your name clearly. Again, please press star one.

Cindy Brach: And just to elaborate a little bit on the last response, I think I heard Shelly asking specifically about measures of patient experiences of care. Of course, we at AHRQ would be remiss if we didn't mention the family of surveys that AHRQ has created over the years, known as CAHPS.

As David said, you should choose the instruments that are most appropriate, and reviewers have no instructions to favor one instrument over another. But I just thought I would do due diligence in mentioning CAHPS.

Coordinator: Rachel Kryfke. And please identify your organization.

Rachel Kryfke: I'm with Children's Hospital Wisconsin. And I'm with the special needs program, so we're a primarily tertiary care partnership that we are (unintelligible) to an enhanced medical home for medically complex and fragile children with chronic conditions.

We were wondering if you would be interested in a proposal that measures the impact of more of the population, because each practice only has one or two of these children at a time. How can we promulgate this model and sustain and replicate it?

David Lanier: Rachel, I think this probably would be best for an offline discussion that we could have with you.

Rachel Kryfke: O.k.

David Lanier: Because I would need to know more details about how this is set up and all before giving you that. And I'm not sure that would be helpful to the other people on the call. O.k.?

Rachel Kryfke: O.k., thanks.

Coordinator: Our next question comes from Trina Ford, Marshfield Clinic. Your line is now open.

Trina Ford: Thank you, this is Trina Ford. We're wondering about when the transformation needs to occur. Does it need to occur all at once, or could it be within a year or two?

I'm thinking of a site we have where a number of different care management activities, data collection, and work (coefficiency) process were all implemented within about a year, a year and a half timeframe, and they've been in place now for more than a year.

Cindy Brach: I think that that is a realistic timeframe over which transformation happens. Unfortunately, we can't wave a magic wand and have transformation by the end of the week. So, while David emphasized that we don't want just incremental change over many years, over a year, or even 18 months, might not be a bad timeframe.

Trina Ford: Thank you.

Cindy Brach: I do also want to just recognize that we realize that we are talking about studying real-world situations and they can often be messy. So the real challenge is going to be to show in your methodology how you're going to learn from those messy situations.

Coordinator: Our next question comes from Sharon Grass, Saint Geneva County Memorial Hospital. Your line is now open.

Sharon Grass: Thank you for taking the call. I have a question. Do you have to be certified as a PCMH at this point?

David Lanier: No, no. We do reference NCQA criteria, and we encourage you to use that in terms of evaluating your practices, but actual certification at any level by NCQA or by any other body is not required. What you do need to do, whether you're certified or not, is to describe to us what's actually happened to transform the practice.

Cindy Brach: In fact, you don't have to fit NCQA's model of a primary care patient-centered medical home at all.

Sharon Grass: Then can I ask another question? We're trying to decide if our practice qualifies. We've been looking at the medical home concept for a little while now, and we've implemented our electronic health record for 2 years at our seven clinics.

Not everybody is quite there. They're at different processes, and about 18 months ago, we implemented other changes that will move us toward the medical home with a registry system and that. And now we're wanting to implement some other changes that would move us further along.

Cindy Brach: I'm going to ask you to take this conversation offline.

Sharon Grass: O.k.

Cindy Brach: Because it deals with the specifics of your situation, whereas we're trying to get at questions that will be of general interest to everyone on the call. E-mail us at the address that is in the RFA, and we can take this up with you.

Sharon Grass: O.k., thank you.

Coordinator: Our last question comes from Lisa Letourneau, Quality Counts. Your line is now open.

Lisa Letourneau: Hi, thanks. My question is about the measures that are used to assess success. You've talked several times about the need to have nonintervention measures, prior to the transformation, over at least a year before the application, and be able to demonstrate that it's had some success.

It's sort of striking me that the only way to go back and do that would be to look specifically at claims, and potentially clinical measures, assuming the practice has a way to go back and look at that. Unless the intervention of the practice happened to have also done something at baseline like a CAHPS survey or staff experience survey. Otherwise you can't go back and create those baselines.

So is it sufficient to be looking at clinical and cost outcomes in terms of demonstrating success? Because even if you did CAHPS now, you couldn't compare it to anything unless you'd already happened to have done it. So what is the thinking about that?

David Lanier: I think you're absolutely right. And what you need to tell us in your application is what is available to you, whether you've got claims data, whether you've got clinical data, other surveys or other work that was done around the time that you would call your baseline and be creative about it, if you can.

Cindy Brach: I would also note that we seem to be assuming a particular method of analyzing the effects: pre- and post-analyses. We haven't talked about comparison groups at all. While it's important to be able to measure what happened before and after, you may also find it informative to compare the patient-centered medical home practices with some other practices, and that could obviously be done cross-sectionally.

Lisa Letourneau: Great. Thanks.

David Lanier: One other thought that we have here when you're talking about particularly more sophisticated ways of looking at data, both the expertise and the resources may not be available to small practices to do that by themselves. If you do have a group of practices with a lot of energy and interest, we would strongly encourage you to partner with an academic resource center or some research organization that may be in your area or available to work with you from a distance to help you design the type of evaluation that's going to be most valuable and most reflective of the work that you've done.

Cindy Brach: I'm also going to make an offer that is a little bizarre. One of the people who e-mailed us was a delivery site who was interested in being matched up with researchers.

And while I said that we do not have that function, if there are researchers on this call who don't already have sites in mind that they are planning to study and they want to e-mail our PCTransform address to let us know of their availability, we'd be happy to pass their names along to delivery sites who say they're looking for researchers. Little unorthodox, but...

David Lanier: We've become a matching system here, yes.


Cindy Brach: Yes, well, I actually proposed an electronic bulletin board for this function, but it didn't seem to have enough volume. So any final questions? Press star one.

David Lanier: O.k. Well, assuming there are no other questions...

Coordinator: One moment, please.

David Lanier: Spoke too soon.

Coordinator: Karen Shifferdecker, Dartmouth Medical, your line is now open.

Karen Shifferdecker: Can you hear me?

David Lanier: Yes.

Karen Shifferdecker: This is Karen Shifferdecker from Dartmouth Medical School. I have a question. I've done quite a bit of mixed-method study, which can be quite time intensive, especially for small practices. I'm wondering in terms of the budget, is there a way of giving some finances to a practice to participate in this study, or could that be an issue?

David Lanier: Yes, it's certainly allowable to have some reimbursement that goes to practices. It really needs to be paying for the time that they put into it. You can't give an honorarium to these practices. But if you are paying for the specific time that they put into this, that would be both understandable and acceptable.

Cindy Brach: And let me say, it's the time spent related to data collection. It could be to free up staff time to provide interviews, or helping pull patient records. It's not to pay them to actually implement some additional change.

Karen Shifferdecker: O.k., I understand. Thank you very much.

Cindy Brach: You're welcome.

Coordinator: Our next question comes from Suzanne Berman, Plateau Pediatrics. Your line is now open.

Suzanne Berman: Thank you. It sounds like what you're looking for is more of a sort of practice revolution as opposed to I guess what I would call a transformation, just in modern lingo.

Using the NCQA perimeters as a guide, if a practice was, say, 10% of the way to meeting 100% score—or Level 3 of the NCQA—and then after a rapid period got to 50, that sounds like you're more interested in that sort of thing as opposed to someone who was 50% of the way there, and then after a period of, you know, PDSA cycles got to 80% over a period of 3 or 4 years. Is that accurate?

David Lanier: Actually, I think either of those would be something that we might be interested in. And if you actually can register on the scale of patient-centered medical home, then we would call that a transformation. Again, it's just determining the before and the after, and I think that's going to be the issue here.

Cindy Brach: Yes, and I just wanted to say a word, because the NCQA measure has come up so frequently on the call. You do not have to feel tied to the NCQA measure. There's a heavy emphasis on health information technology in the scoring of the NCQA measure, and you should not panic and say, “Oh no, we're not eligible,” if you don't meet NCQA's criteria. There are other ways to judge a patient-centered medical home.

David Lanier: And the burden is on you to describe that and convince our reviewers that you actually have transformed the practice, rather than presenting some score based on NCQA criteria.

Suzanne Berman: Great. Thank you.

Coordinator: And again if you have any further questions or comments, please press star one. Again, please press star one.

David Lanier: O.k., I don't see any other questions. I will try again to wrap this up. I wanted to thank you again for your interest. I know when you start writing this, there will be other questions that arise, and I want you to understand that we do have the e-mail address that you can send questions to. Or, if you would like to speak directly to someone, my telephone number is in the RFA as well, or you could also e-mail me directly.

But we would like to be able to be as much assistance as we can to you, and we encourage as many people as possible to apply.

Cindy Brach: And I just want to let people know that a copy of the transcript of this call as well as the questions and answers that were sent yesterday will be posted on the AHRQ Web site connected with the RFA.

David Lanier: If there are no other questions, we thank you all for participating. Have a great weekend.

Cindy Brach: Look forward to seeing your applications.

Coordinator: That concludes today's conference. Thank you for participating. You may disconnect at this time.


Current as of October 2009


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